GPs' decision-making--perceiving the patient as a person or a disease

Turning eating disorders screening in primary practice into treatment: A clinical practice approach

OBJECTIVE

The rate of screening for eating disorders (EDs) by general practitioners (GPs) in primary health care is low. We examined an approach to increase screening and the impact on referrals.

METHOD

Low cost assessment/treatment pathways were established in February 2019 for patients with an ED. Between October 2020 and June 2021 information was sent to GP practices about screening for EDs, along with provision of an online screening tool and training.

RESULTS

Of the 44 GP practices invited to participate in the screening initiative, 42 (95.5%) agreed. Only 12 (27%) had referred patients before the initiative, 53 patients over 19 months (2.8/month). Over the 10-month initiative 90 patients were referred and started treatment from 50% of the practices (8.2/month); 73 (81%) had an ED and six had disordered eating but not an ED. Qualitative feedback from GPs suggested they would not screen for a condition if there were no readily identifiable treatment pathway available.

DISCUSSION

Results suggest that the three elements of the initiative (provision of assessment and treatment pathways, access to a screening tool, provision of information on screening) increased the likelihood that GPs would use a screening tool, leading to an almost three-fold increase in referrals.

PUBLIC SIGNIFICANCE

An initiative used to translate screening for an eating disorder to treatment in primary health care had three components. First, provision of an easy referral process to assessment as well as treatment. Second, screening tools were made available on computer desktops. Third, information and training provided to GPs was used to support their clinical observation and increase confidence in initiating screening. Adoption of this initiative almost tripled referrals for assessment.

General practice - a fertile lagoon in the ocean of medical knowledge

General practitioners (GPs) often find that linear, deductive knowledge does not provide a sufficient map for clinical management. But experience, accompanied by enduring familiarity with individual patients, may offer unique complementary skills to interpret a patient's symptoms and navigate skilfully through diagnosis, treatment, follow-up and prevention.In this article, we draw attention to the nature of this tacit knowing that is executed by many GPs every day. We argue that the nonlinear, unpredictable complexity of this domain nurtures a particular logic of clinical knowing. This kind of knowledge is not intuition and can to some extent be intersubjectively accessible. We substantiate and discuss how and why general practice research can contribute to knowledge development by transforming reflection-in-action to reflection-on-action.We briefly present some concepts for reflection-on-action of clinical knowing in general practice. The VUCA model (volatility, uncertainty, complexity, ambiguity) embraces dynamic and confusing situations in which agile work (adaptive, flexible and responsive behaviour and cognitive creativity) is assumed to be an appropriate response. Using such perspectives, we may sharpen our gaze and apply reflexivity and analytic elaboration to interpret unique incidents and experiences and appreciate the complexity of general practice. In this way, exploratory research can fertilize general practice and offer innovation to the entire domain of clinical knowledge.

Accuracy of the general practitioner's sense of alarm when confronted with dyspnoea and/or chest pain: a prospective observational study

OBJECTIVES

Dyspnoea and chest pain are symptoms shared with multiple pathologies ranging from the benign to life-threatening diseases. A Gut Feelings Questionnaire (GFQ) has been validated to measure the general practitioner's (GPs) sense of alarm or sense of reassurance. The aim of the study was to estimate the diagnostic test accuracy of GPs' sense of alarm when confronted with dyspnoea and chest pain.

DESIGN AND SETTINGS

Prospective observational study in general practice.

PARTICIPANTS

Patients aged between 18 and 80 years, consulting their GP for dyspnoea and/or chest pain, were considered for enrolment. These GPs had to complete the GFQ immediately after the consultation.

PRIMARY OUTCOME MEASURES

Life-threatening and non-life-threatening diseases have previously been defined according to the pathologies or symptoms in the International Classification of Primary Care (ICPC)-2 classification. The index test was the sense of alarm and the reference standard was the final diagnosis at 4 weeks.

RESULTS

25 GPs filled in 235 GFQ questionnaires. The positive likelihood ratio for the sense of alarm was 2.12 (95% CI 1.49 to 2.82), the negative likelihood ratio was 0.55 (95% CI 0.37 to 0.77).

CONCLUSIONS

Where the physician experienced a sense of alarm when a patient consulted him/her for dyspnoea and/or chest pain, the post-test odds that this patient had, in fact, a life-threatening disease was about twice as high as the pretest odds.

TRIAL REGISTRATION NUMBER

NCT02932982.

Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences

Objective: Explore general practitioners' (GPs') views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs' views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members' roles must be clear. KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs' experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

Development of a toolkit for early identification of cauda equina syndrome

Aim

To develop a simple cauda equina syndrome (CES) toolkit to facilitate the subjective examination of low back pain patients potentially at risk of CES. To undertake preliminary validation of the content of the toolkit.

Background

CES is a rare condition which can be very challenging to identify in a generalist medical setting.

Method

A three phase iterative design with two stake holder groups; extended scope practitioners experienced in managing CES patients and CES sufferers.

Toolkit development

Synthesis of existing CES literature with CES patient data generated from in depth interviews.

Toolkit validation

Content validation of the draft toolkit with CES patients.

Toolkit validation

Content validation of the draft toolkit with extended scope physiotherapists.

Findings

A three arm toolkit has been developed for use with patients considered by the clinician as at risk of developing CES (eg, worsening low back pain with symptoms/signs of progressive sensory-motor deficit in the lower limbs); patient expertise, clinical expertise, research and pathways. Uniquely, the toolkit drew upon the lived experiences of patients suffering from CES to inform the content.

Aprendiendo conceptos del diagnóstico en medicina de familia: a propósito del «signo de Robinson» - las huellas que no deberían estar allí

A propósito de cinco casos en donde el proceso diagnóstico se inició en «la huella que no debería estar allí» o «signo de Robinson» –como le pasó a Robinson Crusoe que vio una huella humana en la playa de su isla «desierta»: ¿cómo podía encontrarse allí?; era un misterio–, y basándonos en metáforas, revisamos los mecanismos de la operación mental de identificar la enfermedad en medicina de familia. Encuadramos el mecanismo de «la huella que no debería estar allí» principalmente en la primera fase o intuitiva del razonamiento clínico, pero esta intuición del médico debe mantenerse acompañando a todo el proceso diagnóstico, como el «bajo continuo» de la música barroca, permitiendo la improvisación y el estilo personal, y de este modo, eventualmente la observación de la huella «que no tenía que estar allí» puede surgir tanto en la fase analítica como en la de verificación de las hipótesis elaboradas.

Physician's first clinical impression of emergency department patients with nonspecific complaints is associated with morbidity and mortality

The association between the physician's first clinical impression of a patient with nonspecific complaints and morbidity and mortality is unknown. The aim was to evaluate the association of the physician's first clinical impression with acute morbidity and mortality. We conducted a prospective observational study with a 30-day follow-up. This study was performed at the emergency departments (EDs) of 1 secondary and 1 tertiary care hospital, from May 2007 to February 2011. The first clinical impression ("looking ill"), expressed on a numerical rating scale from 0 to 100, age, sex, and the Charlson Comorbidity Index (CCI) were evaluated. The association was determined between these variables and acute morbidity and mortality, together with receiver operating characteristics, and validity. Of 217,699 presentations to the ED, a total of 1278 adult nontrauma patients with nonspecific complaints were enrolled by a study team. No patient was lost to follow-up. A total of 84 (6.6%) patients died during follow-up, and 742 (58.0%) patients were classified as suffering from acute morbidity. The variable "looking ill" was significantly associated with mortality and morbidity (per 10 point increase, odds ratio 1.23, 95% confidence interval [CI] 1.12-1.34, P < 0.001, and odds ratio 1.19, 95% CI 1.14-1.24, P < 0.001, respectively). The combination of the variables "looking ill," "age," "male sex," and "CCI" resulted in the best prediction of these outcomes (mortality: area under the curve [AUC] 0.77, 95% CI 0.72-0.82; morbidity: AUC 0.68, 95% CI 0.65-0.71). The physician's first impression, with or without additional variables such as age, male sex, and CCI, was associated with morbidity and mortality. This might help in the decision to perform further diagnostic tests and to hospitalize ED patients.

Managing risk in cancer presentation, detection and referral: a qualitative study of primary care staff views

OBJECTIVES

In the UK, there have been a number of national initiatives to promote earlier detection and prompt referral of patients presenting to primary care with signs and symptoms of cancer. The aim of the study was to explore the experiences of a range of primary care staff in promoting earlier presentation, detection and referral of patients with symptoms suggestive of cancer.

SETTING

Six primary care practices in northwest England.

PARTICIPANTS

39 primary care staff from a variety of disciplines took part in five group and four individual interviews.

RESULTS

The global theme to emerge from the interviews was 'managing risk', which had three underpinning organising themes: 'complexity', relating to uncertainty of cancer diagnoses, service fragmentation and plethora of guidelines; 'continuity', relating to relationships between practice staff and their patients and between primary and secondary care; 'conflict' relating to policy drivers and staff role boundaries. A key concern of staff was that policymakers and those implementing cancer initiatives did not fully understand how risk was managed within primary care.

CONCLUSIONS

Primary care staff expressed a range of views and opinions on the benefits of cancer initiatives. National initiatives did not appear to wholly resolve issues in managing risk for all practitioners. Staff were concerned about the number of guidelines and priorities they were expected to implement. These issues need to be considered by policymakers when developing and implementing new initiatives.

Developing an early alert system for metastatic spinal cord compression (MSCC): Red Flag credit cards

AIM

To produce a user-friendly list of metastatic spinal cord compression (MSCC) Red Flags for non-specialist 'generalist' front-line clinicians working in primary-care settings.

BACKGROUND

The issue of identifying MSCC early to prevent serious long-term disability was a key theme identified by the Task and Finish Group at Greater Manchester and Cheshire Cancer Network (GMCCN) in 2009. It was this group who initially brokered and then coordinated the current development as part of their strategic approach to improving care for MSCC patients.

METHODS

A consensus-building approach that considered the essential minimum data requirements to raise the index of suspicion suggestive of MSCC was adopted. This followed a model of cross-boundary working to facilitate the mutual sharing of expertise across a variety of relevant clinical specialisms.

RESULT

A guideline aimed at helping clinicians to identify the early signs and symptoms of MSCC was produced in the form of a credit card. This credit card includes key statements about MSCC, signposting to key sources of additional information and a user-friendly list of Red Flags which has been developed into an eight-item Red Flag mnemonic. To date, an excess of 120,000 cards have been printed by a variety of organisations and the distribution of the cards is ongoing across the United Kingdom and the Republic of Ireland.